Bone Graft Policy (001)

Subject: Use of Bone Grafts in Conjunction with Apicoectomies, Extractions and/or Implants

Reviewed: November 22, 2016

Important note

This Clinical Policy Bulletin expresses Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).

Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in this Bulletin. The discussion, analysis, conclusions and positions reflected in this Bulletin, including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna’s opinion and are made without any intent to defame.

Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. New and revised codes are added to the CPBs as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided.

Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.

The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (for example, will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members.

Policy

Aetna considers this surgical procedure to be dental-in-nature (DIN) oral surgery. Coverage may be available for DIN oral surgery procedures under either medical or dental plans. Necessity and appropriateness will be determined through review of corresponding diagnostics and a rationale if necessary. Need for bone grafts used in conjunction with apicoectomies, extractions and/or implants will be based on a clinical scenario in which normal healing cannot be expected.

Background

Bone grafts have been used in conjunction with endodontic, oral surgery, implants and periodontal procedures for years. Studies have clearly demonstrated the potential to realize significant histological and clinical improvement following regenerative therapy. Studies have also demonstrated that the healing capacity of the body following these procedures is able to regenerate/repair lost hard and soft tissue. The use of bone grafts would not appear to be indicated in every clinical situation, depending on a variety of factors.

The vast majority of surgical sites heal without significant defects. In some situations, however, bone grafting may result in a long-term benefit. Large defects associated with apicoectomy/cyst removal extending outside of the tooth’s alveolar space may benefit from bone graft-assisted regeneration. Bone grafts in extraction sockets are not routinely indicated. However, they have been shown to be beneficial in ridge preservation when implant replacement is intended.

There is also increasing evidence that bone grafting after third molar removal may be beneficial in reducing periodontal defects on the distal of second molars in a certain “high-risk” subpopulation (for example, age greater than 26 years and significant existing periodontal defects). Bone grafting may also be beneficial at the time of implant placement when the available volume of bone at the site is not adequate.

Bone grafts are indicated only when they are medically necessary for the success of the procedure being performed, or when normal healing cannot be expected to eliminate the bony defect.

Ridge augmentation [code D7950] and sinus lift procedures [code D7951/D7952] are used in implant placement when sites are deficient in height or width. These codes are medical-in-nature codes and are reviewed as to medical necessity in their own right.

Codes1,2

D3428 – Bone graft in conjunction with periradicular surgery-per tooth, single site
D3429 – Bone graft in conjunction with periradicular surgery-each additional contiguous tooth in the same surgical site
D6104 – Bone graft at the time of implant placement
D7950 – Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla- autogenous or nonautogenous, by report
D7951 – Sinus augmentation with bone or bone substitutes
D7952 – Sinus augmentation via a vertical approach
D7953 – Bone replacement graft for ridge preservation – per site

Revision Dates

Original policy: September 13, 2004
Updated: February 24, 2009; October 4, 2010; January 23, 2012; December 4, 2012; November 5, 2013, December 8, 2014; November 23, 2015; November 22, 2016
Revised: December 5, 2005; March 10, 2008

Property of Aetna. All rights reserved. Dental Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical/dental advice. This Dental Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating health care professionals are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating health care professionals are solely responsible for medical/dental advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

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Clinical Policy Bulletins

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Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Treating providers are solely responsible for dental advice and treatment of members. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider.

While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Your benefits plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government.

Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change.

Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies.

Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met.